Insurance companies, including Medicare, cover procedures in which there is a functional deficit that can be fixed with a certain procedure. Insurance companies typically follow criteria established by the Center for Medicaid and Medicare Services (CMS). These criteria cannot be challenged by you, your referring doctor, or our practice. An insurance company can drop our practice if we do not follow their criteria. Likewise, an insurance company can drop your policy if you misrepresent your symptoms in order for insurance to cover a procedure.
Our practice is currently in-network with Medicare and we offer competitive self pay rates for those patients with commercial insurance.
Is My Visit Covered?
Dr. Connor is not able to treat or diagnose your condition over the phone. If you have a condition that is deemed to cause a functional deficit, the visit will be submitted to insurance for payment. You are responsible for your co-payment prior to being seen by the doctor. Your insurance company determines the level of payment and your financial responsibility. This includes a co-payment, co-insurance, and a deductible amount. You are responsible for knowing and understanding each one. Please note that if you have a minor procedure at the time of your visit, there may be an additional amount owed at the time of service. This amount is determined by the specific policy you or your employer have chosen.
Numerous diagnoses and procedures in oculoplastic surgery are considered cosmetic. Cosmetic surgery is elective and is never covered by insurance. Furthermore, a cosmetic consultation is not covered by insurance, and you are responsible for the consultation fee prior to being evaluated by the doctor. Occasionally, your co-payment may be collected by the front office staff and your findings are actually considered cosmetic. In such instances, you will be responsible for the balance of a cosmetic consultation upon checkout. Cosmetic consultations cannot be submitted or partially submitted to your insurance company.
Is My Surgery Covered?
Once you have been evaluated by Dr. Connor and surgery has been recommended, if you have a functional impairment and meet strict criteria established by Medicare, your information will be sent for prior authorization when required. Please note that prior authorization does not guarantee payment.
If you do not meet the criteria, the office will not attempt to put your surgery through insurance. The patient and Dr. Connor both have a contract to follow their rules and criteria. Any attempt by a patient to represent a cosmetic procedure as reconstructive is unethical and fraudulent.
Complications from previous cosmetic surgery cannot be submitted to insurance. The patient is responsible for the consultation fee and any surgery required to correct the complication.
There are many intricacies when navigating through the myriad of insurance rules and requirements. If at any time, you have any questions regarding the process, please feel free to contact us and we would be happy to address any of your concerns.